History of Present Illness:
The patient is a year old with acute respiratory distress.
The patent is currently on the ventilator
The patient is expected to need mechanical ventilation
for prolonged period of time.
The patient is also expected to need help with nutritional support
via enteral feed.
PEG and Trach has been recommended for continue care and recovery
Past Medical History
Social History -
Home Medication - Reviewed
Allergies - Reivewed
REVIEW OF SYSTEMS:
Pt is sedated on the ventilatory so the history, ROS were reviewed from the
documents in the chart as well as discussion with the pt's caretakers.
GENERAL: Pt is weak, requires continual support
HEENT: No gross abnormality
Eyes: No gross abnormality
Ears: No gross abnormality
Nose: No gross abnormality
Throat: No gross abnormality
LUNGS: pt with acute respiratory distress and requires mechanical ventilation
CARDIAC: No chest pain. Rate and Rhythms are monitored
GI: Nausea. No vomiting. No diarrhea. NO Abdominal pain. No vomiting blood. No rectal bleeding.
GU: No frequency. No hesitancy. No hematuria. No pyuria. Pt has urinary catheter and output is
being monitored
NEUROLOGIC:
MUSCULOSKELETAL: when off of sedation, pt has full ROM.
Vitals:
Physical Examination
GA: comfortable, no distress
HEENT: Atraumatic; normo-cephalic;
Eyes: EOMI, PERRLA
Nose: Nares patent, no sign of bleeding
Throat: Mouth is clear and no adenopathy, no deviation
NECK: Supple, no adenopathy, and no thyromegaly
LUNGS: No rhonchi, no wheezing. Bilateral
CHEST: Symmetrical excursion
CARDIAC: Regular, rate, & rhythm
ABDOMEN: +BS, Soft, Non-distended, No obvious organomegaly, and no obvious masses
EXTREMITIES: No cyanosis, No clubbing, No edema
SKIN: No lesions
NEURO: sedated on the ventilator
Imaging:
I have personally reviewed the imaging studies
Labs:
Assessments and Plans:
The patient is a
with acute respiratory failure
The patient is now intubated and is expected
to be dependent on mechanical ventilation
for prolonged period of time
The patient will benefit from a tracheostomy as well as enteral access via PEG
for enteral feeding
Will discuss with the pt's caregiver and POA regarding
the proposed procedures, risks, benefits, as well as alternative prior to
the procedure.